Re: [ozmidwifery] But there is Dr delay to the story from NZ
There is a definite media bias in both Oz and NZ when it comes to midwifery/doctor involvement in Birth issues especially in the area of maternal/neonatal mortality. Interesting to note that the coroner in other recent cases in NZ has made recommendations for improvements but has not blamed/challenged the system in use in NZ. rgds mike On 3/23/06, Susan Cudlipp <[EMAIL PROTECTED]> wrote: What I cannot understand here is that the woman was transferred at 23.45hours for mec liquor, and "sat on" for the next 5 hours, presumably being monitored by CTG all that time with the mec getting thicker. How come the midwives are copping the blame here? The attending midwife obviously transferred appropriately, it would appear to be hospital mis-management, either lack of monitoring, inexperience in reading the monitor, or lack of appropriate assessment by doctor on duty. Either way, to allow a woman to labour with fetal distress which must have been increasing for the babe to be so compromised is certainly unforgiveable - but why was she left so long? That is the question that needs to be answered. Even in hospital care the doctor was 'too busy' to assess this poor woman? Tragic. Sue "The only thing necessary for the triumph of evil is for good men to do nothing"Edmund Burke - Original Message - From: B & G To: ozmidwifery@acegraphics.com.au Sent: Monday, March 20, 2006 6:39 PM Subject: [ozmidwifery] But there is Dr delay to the story from NZ Just read the fuller details. Seems to me the midwives took her to hospital correctly but a huge delay in being seen by the Dr! Seems to me there is scaremongering going on. Love to know more about the Dr stats. Barb This article is owned by, or has been licensed to, the New Zealand Herald. You may not reproduce, publish, electronically archive or transmit this article in any manner without the prior written consent of the New Zealand Herald. To make a copyright clearance inquiry, please click here. Alan and Heather Phillips place flowers at the grave site of their baby daughter Tyla in Awhitu. Picture / Kenny Rodger Baby died after hospital errors 20.03.06By Martin Johnston Another baby has died after a series of mistakes partly blamed on midwife care. Tyla Phillips survived for only 7 hours after she was born at Middlemore Hospital in an emergency caesarean operation last August. A hospital specialist later told her parents, Heather and Alan Phillips, that if the operation had been performed three hours earlier she might have lived. The specialist said midwives misread a fetal heart rate monitor. The couple now want an inquiry into maternity and midwifery care because their case follows other newborn deaths with similar themes. Middlemore is saying little publicly about Tyla's birth until the Accident Compensation Corporation has reported its decision to the hospital and Health and Disability Commissioner Ron Paterson has investigated. The hospital says it may refer the case, which had devastated the staff involved, to the commissioner, or medical or midwifery bodies. However, hospital documents and a tape recording the Phillips have of one of their meetings with senior clinicians catalogue the mistakes that led to Tyla's death on August 18 and a follow-up internal review. A key failure was midwives' mis-reading of a fetal heart rate monitor, according to the obstetric consultant on call at the time, Dr Alec Ekeroma, on the tape. He also indicated that the fetal blood-acidity test which led to the caesarean decision - done after an obstetric registrar reviewed the heart monitoring - was unnecessary in the circumstances and wasted time. He said the 21-minute caesarean operation - Tyla was born at 5.53am - should have been done "probably two or three hours earlier". If it had been, this "may have changed the outcome". Mrs Phillips was several days overdue when she went to the Middlemore-allied Botany Downs Maternity Unit, which was managing her pregnancy. The unit's midwives had her transferred to Middlemore at 11.45pm on August 17. Her waters had broken around 9pm, containing what her medical file says was "moderate meconium" (faeces from the baby). Staff noticed thick m
Re: [ozmidwifery] But there is Dr delay to the story from NZ
Title: Message What I cannot understand here is that the woman was transferred at 23.45hours for mec liquor, and "sat on" for the next 5 hours, presumably being monitored by CTG all that time with the mec getting thicker. How come the midwives are copping the blame here? The attending midwife obviously transferred appropriately, it would appear to be hospital mis-management, either lack of monitoring, inexperience in reading the monitor, or lack of appropriate assessment by doctor on duty. Either way, to allow a woman to labour with fetal distress which must have been increasing for the babe to be so compromised is certainly unforgiveable - but why was she left so long? That is the question that needs to be answered. Even in hospital care the doctor was 'too busy' to assess this poor woman? Tragic. Sue "The only thing necessary for the triumph of evil is for good men to do nothing"Edmund Burke - Original Message - From: B & G To: ozmidwifery@acegraphics.com.au Sent: Monday, March 20, 2006 6:39 PM Subject: [ozmidwifery] But there is Dr delay to the story from NZ Just read the fuller details. Seems to me the midwives took her to hospital correctly but a huge delay in being seen by the Dr! Seems to me there is scaremongering going on. Love to know more about the Dr stats. Barb This article is owned by, or has been licensed to, the New Zealand Herald. You may not reproduce, publish, electronically archive or transmit this article in any manner without the prior written consent of the New Zealand Herald. To make a copyright clearance inquiry, please click here. Alan and Heather Phillips place flowers at the grave site of their baby daughter Tyla in Awhitu. Picture / Kenny Rodger Baby died after hospital errors 20.03.06By Martin Johnston Another baby has died after a series of mistakes partly blamed on midwife care. Tyla Phillips survived for only 7 hours after she was born at Middlemore Hospital in an emergency caesarean operation last August. A hospital specialist later told her parents, Heather and Alan Phillips, that if the operation had been performed three hours earlier she might have lived. The specialist said midwives misread a fetal heart rate monitor. The couple now want an inquiry into maternity and midwifery care because their case follows other newborn deaths with similar themes. Middlemore is saying little publicly about Tyla's birth until the Accident Compensation Corporation has reported its decision to the hospital and Health and Disability Commissioner Ron Paterson has investigated. The hospital says it may refer the case, which had devastated the staff involved, to the commissioner, or medical or midwifery bodies. However, hospital documents and a tape recording the Phillips have of one of their meetings with senior clinicians catalogue the mistakes that led to Tyla's death on August 18 and a follow-up internal review. A key failure was midwives' mis-reading of a fetal heart rate monitor, according to the obstetric consultant on call at the time, Dr Alec Ekeroma, on the tape. He also indicated that the fetal blood-acidity test which led to the caesarean decision - done after an obstetric registrar reviewed the heart monitoring - was unnecessary in the circumstances and wasted time. He said the 21-minute caesarean operation - Tyla was born at 5.53am - should have been done "probably two or three hours earlier". If it had been, this "may have changed the outcome". Mrs Phillips was several days overdue when she went to the Middlemore-allied Botany Downs Maternity Unit, which was managing her pregnancy. The unit's midwives had her transferred to Middlemore at 11.45pm on August 17. Her waters had broken around 9pm, containing what her medical file says was "moderate meconium" (faeces from the baby). Staff noticed thick meconium when she arrived at the hospital. The presence of meconium can indicate a distressed baby. Because of this, the Phillips expected a caesarean on arrival at Middlemore. Mrs Phillips said she was not fully assessed by an obstetric doctor until about 5am. Her medical file states a registrar was asked to see her after her arrival
[ozmidwifery] But there is Dr delay to the story from NZ
Title: Message Just read the fuller details. Seems to me the midwives took her to hospital correctly but a huge delay in being seen by the Dr! Seems to me there is scaremongering going on. Love to know more about the Dr stats. Barb This article is owned by, or has been licensed to, the New Zealand Herald. You may not reproduce, publish, electronically archive or transmit this article in any manner without the prior written consent of the New Zealand Herald. To make a copyright clearance inquiry, please click here. Alan and Heather Phillips place flowers at the grave site of their baby daughter Tyla in Awhitu. Picture / Kenny Rodger Baby died after hospital errors 20.03.06By Martin Johnston Another baby has died after a series of mistakes partly blamed on midwife care. Tyla Phillips survived for only 7 hours after she was born at Middlemore Hospital in an emergency caesarean operation last August. A hospital specialist later told her parents, Heather and Alan Phillips, that if the operation had been performed three hours earlier she might have lived. The specialist said midwives misread a fetal heart rate monitor. The couple now want an inquiry into maternity and midwifery care because their case follows other newborn deaths with similar themes. Middlemore is saying little publicly about Tyla's birth until the Accident Compensation Corporation has reported its decision to the hospital and Health and Disability Commissioner Ron Paterson has investigated. The hospital says it may refer the case, which had devastated the staff involved, to the commissioner, or medical or midwifery bodies. However, hospital documents and a tape recording the Phillips have of one of their meetings with senior clinicians catalogue the mistakes that led to Tyla's death on August 18 and a follow-up internal review. A key failure was midwives' mis-reading of a fetal heart rate monitor, according to the obstetric consultant on call at the time, Dr Alec Ekeroma, on the tape. He also indicated that the fetal blood-acidity test which led to the caesarean decision - done after an obstetric registrar reviewed the heart monitoring - was unnecessary in the circumstances and wasted time. He said the 21-minute caesarean operation - Tyla was born at 5.53am - should have been done "probably two or three hours earlier". If it had been, this "may have changed the outcome". Mrs Phillips was several days overdue when she went to the Middlemore-allied Botany Downs Maternity Unit, which was managing her pregnancy. The unit's midwives had her transferred to Middlemore at 11.45pm on August 17. Her waters had broken around 9pm, containing what her medical file says was "moderate meconium" (faeces from the baby). Staff noticed thick meconium when she arrived at the hospital. The presence of meconium can indicate a distressed baby. Because of this, the Phillips expected a caesarean on arrival at Middlemore. Mrs Phillips said she was not fully assessed by an obstetric doctor until about 5am. Her medical file states a registrar was asked to see her after her arrival but was busy in theatre. At 5.32am the decision was made to deliver Tyla by caesarean after the blood-acid test - which had consumed 20 minutes, after one attempt at the test failed - confirmed her distress. A report on Tyla's post-mortem says her lungs had suffered "massive meconium inhalation" and extensive bleeding, and she had brain damage from oxygen deprivation. A Middlemore document describes the events surrounding the birth and poor follow-up with the parents as a "multi-system failure". A letter to ACC by clinical director of women's health Dr Keith Allenby lists 11 recommendations being considered to address some of the issues the case has highlighted. These include clarifying what should be done in response to abnormalities revealed by fetal heart rate monitoring; regular training, for all pregnancy-care staff, in interpreting the monitoring results; and clarifying the chain of contact "if obstetric registrar busy (as new tier of doctors now in place)". The Phillips have lost confidence in New Zealand's midwife-dominated maternity system. "If I could do it again," said 33-year-old Mrs Phillips, who had difficulty conceiving Tyla, "I wouldn't go the midwife way. I would go to a doctor, a specialist." Tyla's case follows crit
